Anybody on Medicare and pumping?

iPat

Posted 21 August 2010 - 08:45 AM

iPat

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I am new as of this year to Medicare but not new to pumping (12 years) I have no trouble getting my pump supplies from Medtronic through Medicare but Ive found myself in what's called the "donut hole" when it comes to medication. I have six weeks worth of Apidra insulin left before I run out. Ive heard conflicting information (from patients AND Medicare) that when youre on an insulin pump, the donut hole does not apply to your insulin.

Does anybody have any experience with running out of insulin before the end of the year? The cheapest I can find it is through Costco and it's $110 per vial. Help! iPat

jwags

Posted 21 August 2010 - 10:18 AM

jwags

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I am a:Type 2

I'm not sure the specific rules on the donut hole but I thought they were fixing that with the new healthcare bill. Go to Health Care - | HealthCare.gov and check it out. As far as cheapest places to buy insulin check out the Canadian pharmacies. We buy our meds from Northwest Pharmacy in British Columbia. I know the insulin pens are less than 1/2 the price.

poodlebone

Posted 21 August 2010 - 10:29 AM

poodlebone

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I have no experience with Medicare but if you are running low and can't afford the cost maybe you could ask your doctor/endo for samples? They often have vials to give to patients. I don't know about Apidra but I think the makers of Humalog & Novolog have some kind of patient assistance programs. Setting that up might take awhile, though. I believe it depends on income and your doctor has to fill out forms.

I have no idea what a donut hole is and if it refers to prescription drugs on Medicare but I thought that insulin for pumpers was covered no matter what? You can go to the Medicare site and search for your state to see what it says. For example, I entered my state and chose the Diabetes - Insulin & Syringes and the Durable Medical Equipment options. This is what it says under the Insulin & Syringes section:

If you use an external insulin pump, insulin and the pump could be covered as durable medical equipment. There may be some limits on covered supplies or how often you get them. For more information, please refer to the coverage information listed under Durable Medical Equipment.

Under the DME section it has some more info and basically says that your doctor must prescribe it, the supplier you get the insulin from must have a Medicare DME Supplier number.

Bountyman

Posted 21 August 2010 - 11:57 AM

Bountyman

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I am a:Type 2

I'm also on Medicare and tried reading the circular they sent me a few months ago about the 'donut hole'. When I'm stumped I usually call Medicare and they walk me through my concerns, you might try that. 1-800-MEDICARE.

Subby

Posted 21 August 2010 - 12:12 PM

Subby

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I haven't got a clue about donhuts holes or anything like that, and I hope you find a way to keep with a good supply with your preferred insulin. But just another idea if things get grim is that I have heard of people pumping with a fast rather than a rapid insulin. In other words, the older generation, actrapid, humulin. Which, to cobble together another bit of second hand information I have heard is available cheaply in the US.

Insulin action wise, it could be a pain or it could be fine. If you go this route be sure to check out which is safe to use: I believe there is one that is fine in the pump and one that is not, something to do with being unbuffered or the like. Be best to run it by an endo if you can.

iPat

Posted 21 August 2010 - 05:13 PM

iPat

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Hi Folks...
Thanks for responding to my post! I appreciate the comments!

I stood my ground with Medicare today and yes, if youre on an insulin pump, your insulin is paid for under Part B (Durable Medical Equipment) not Part D (drugs) I had to insist that this was so with the two Medicare employees I talked to but finally they were able to document that insulin with a pump was in fact covered.

I called CVS today and told them that they needed to bill Medicare under Part B instead of Part D. The pharmacist said she would check into it and call me back. She called back and said that indeed I was right that Medicare does pay for insulin when used in an infusion pump. She said that CVS needed "documentation" and I asked what all that included and the pharmacist said, "Frankly, I don't know".

I suggested that she run the prescription she has on file through Medicare and she thought that might just work. So the question remains, what kind of documentation?

I think there probably are a small number of us "seniors" on pump therapy and the Medicare folks just dont have any experience with this......either do the pharmacists.

GrammaBear

Posted 21 August 2010 - 06:10 PM

GrammaBear

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I just started Medicare July 1st and the Medtronic Revel on August 20th, so I have very little experience with Medicare and the donut hole. I'm glad you called Medicare and stood your ground. I think you're right that there are a small number of "seniors" on the pump so Medicare probably don't know what to do with us? Keep up the good work and I hope you're able to resolve your concerns.

poodlebone

Posted 21 August 2010 - 10:37 PM

poodlebone

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Hi Folks...I stood my ground with Medicare today and yes, if youre on an insulin pump, your insulin is paid for under Part B (Durable Medical Equipment) not Part D (drugs) I had to insist that this was so with the two Medicare employees I talked to but finally they were able to document that insulin with a pump was in fact covered.

Good for you! I'm not on Medicare but my CDE, who generally writes my prescriptions (she's a nurse practitioner) writes "insulin pump" on all of my diabetes prescriptions. For strips, she'll write "Test X times a day on insulin pump". For Humalog it's X units per day on insulin pump. Just make sure that your doctor writes for a little more than your average daily total. Take the insulin wasted in the tubing and during priming into account. I've had to fight with pharmacists over the way a prescription was written because they said 2 vials was more than a 30 day supply but 1 wasn't enough. My CDE now overwrites the amounts so I won't have to fight with them or run short.

DennisIDDM

Posted 22 August 2010 - 10:39 PM

DennisIDDM

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Well Pat, let me know if They will actauly cover the Aphidra vs The Traditional Novalog..
I have yet to find a Fellow Medicare Pumper that it does..
and I also being New On Medicare, cannot Get a Pump yet, since I've been told MY BG's are too good... <6% A1c's
So maybe best to Get a Pump Before Going On Medicare ? But in most cases, they only give them to those Having Control Problems with higher than 6% A1c's...or so I have been told..

and this will become more and more of a problem for future Seniors.. seeing as more and more D's are getting on them in their Pre-Medicare yrs and alot of Babyboomers are comming!

GrammaBear

Posted 23 August 2010 - 09:55 AM

GrammaBear

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I am a:Type 1

I have no idea if it is true...but my Endo told me that Medicare bases their requirements for granting a pump for Seniors on the results of the c-peptide test, your BG results for the past 3 months and one other test (that I've forgotten the name of - sorry). And I've also been told that at present Medicare only covers Humalog and Novolog and again, not sure why they don't cover Apidra. Maybe because it is new and Medicare seems to be slow in covering "new" things??

donkorte

Posted 12 August 2011 - 12:17 AM

donkorte

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Insulin is covered under Medicare drug cover Part "D" when injecting but when using Insulin via a pump it is covered Medicare Part "B" so there is NO donut hole to worry about. It is covered just like docotr visits and lab work is covered. For anybody that is still injecting Insulin and does hit the donut hole I found Lilly Humalog in Mexico for $30+ per vial compared to $110 in the US. I was asked if I was concerned about using this Insulin and since I test 4-6 times a day I would know very quickly if there was a problem with it. We live in Indiana but winter in Mesa AZ and it is only a 120 mile drive to Algodones Mexico border town and get the Insulin. I bought my Insulin there for 2 years when I was hitting the donut hole way to early but now I am on a pump and don't need to go the Mexico to buy it. You can only buy 90 days supply of any drug. Also, you don't need a prescription to buy Humalog.

dgz924s

Posted 12 August 2011 - 10:22 AM

dgz924s

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The "donut hole" is based solely on what has been spent. If you reach the amount of 2800.00 or so in change the donut hole take place. From that point the cost of meds is up to the patient until you hit the 4500.00 mark then "catastrophic coverage" takes over and pays the total cost of meds....So to be exact you have to pay the first 310.00 deductable then insurance kicks in and pays 80% of the cost to an amount of 2840.00, this total amount includes copays and deductables. Once yo go over the 2840.00 amount you are responsible for the cost until you spend 4550.00 then insurance kicks back in and pays the total cost. This continues until the year end then the "game" starts all over again for the new year. You can be waived of the "coverage gap aka "donut hole" by qualifying for "extra help from Medicare", this is a program that assists the low income members. Under this plan the amount of 2840.00 is waived and insurance continues to pay once you go above that amount.

So in sum if you have spent 2840.00+ to date all meds will be "out of pocket" and thus getting a rejection from Medicare not paying the cost of your insulin. Part B should be covering the cost and there is no coverage gap that applies on amount spent.

You should contact your Pharmacy and ask what plan is being billed for the insulin and thay say Part D then you need to take action to get them to bill Part B.

One way you can avoid shortages is to have the Doctor write the prescription on a "sliding scale" for the use of an "extrenal insulin pump device" and this should help you have the amount of insulin needed and/or redirect the billing to Part B.

dgz924s

Posted 12 August 2011 - 11:09 AM

dgz924s

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I have no idea if it is true...but my Endo told me that Medicare bases their requirements for granting a pump for Seniors on the results of the c-peptide test, your BG results for the past 3 months and one other test (that I've forgotten the name of - sorry). And I've also been told that at present Medicare only covers Humalog and Novolog and again, not sure why they don't cover Apidra. Maybe because it is new and Medicare seems to be slow in covering "new" things??

In 2009 Medicare did cover Apidra but in 2010 they did not but this all depends on the State in which you live and the plan or underwriter you are covered by. In 2011 they only cover Humalog, all varieties, Novolog/Novolin all varieties, Lantus and Levemir. This said it all depends on the "underwriter of your plan" i.e. United Healthcare, Cigna, CCRx, Humana etc. You can check your formulary for what drugs are covered, if you do not have it available, contact the insurance company that underwrites your plan to send you one.

Now for why some meds are not covered any longer....all providers enter into a contract with Medicare and agree to waive a percentage of the cost of the meds billed to Medicare. Medicare NEVER pays the amount you and I would pay out of pocket so the provider "takes a hit". They can only absorb so much of a loss before they can no longer provide the meds to be covered by Medicare so they do not sign up for a contract to do so. The makers of Apidra most likely fall into this senario and said "screw it" and dropped out of the program. The other is just the opposite, when Medicare cannot afford to pay the percentage the provider needs they drop them from the provider list. An example of this was when Medicare paid for E.D. Meds, i.e. Viagra. They did pay for a very short period but soon dropped it due to cost and demand put on to the Medicare system.

NoraWI

Posted 14 August 2011 - 11:45 AM

NoraWI

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I am a:Type 1

I am on Medicare, which *leases* my pump from Animas and pays for the insulin that is used in the pump under Part B. My pharmacy had a hard time finding the Code under which to bill Medicare for this insulin but they persisted and were finally successful. It all depends upon how hard the pharmacy wants to try. My NP CDE has to write an Rx for the *insulin used in a pump.* This is renewed every 6 months. I had a positive GAD65 and a low c-peptide on record so had no problem getting Medicare approval.

NoraWI
T1 since 2002, MDI since 2004
Pumping NovoLog with an Animas Ping since May 2010

GrammaBear

Posted 14 August 2011 - 12:45 PM

GrammaBear

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When I asked my Pharmacy to bill Medicare for my insulin used in a pump - under part B, guess what they told me? No can do! In other words, they didn't want to do it. The nearest official supplier that is willing to bill under part B is over 90 miles away from where I live. The hassle of driving that far during the Winter months is too much. I struggle to pay for my insulin under part D - probably because no one really wants to go to the trouble of finding the correct code to bill for it. Sigh....................

poodlebone

Posted 14 August 2011 - 01:00 PM

poodlebone

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I may have asked you this before, but can you find a mail order supplier who is willing to send you insulin under Part B? Also, if a pharmacy accepts Medicare don't they HAVE to bill things correctly? It seems unfair if they're allowed to pick & choose what they're going to do.

dgz924s

Posted 14 August 2011 - 03:15 PM

dgz924s

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Thinking outside the box here but how about asking the doctor to write on the prescription to bill Part B as a part of the script? This would have to be followed as it is a legal order per the doctor. Worth a try. That said Walmart will bill who you ask them to, any chance you have a store nearby?....And as a last ditch effort, get the billing code from the doctor then give it to the pharmacy.

GrammaBear

Posted 14 August 2011 - 03:46 PM

GrammaBear

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I am a:Type 1

I may have asked you this before, but can you find a mail order supplier who is willing to send you insulin under Part B? Also, if a pharmacy accepts Medicare don't they HAVE to bill things correctly? It seems unfair if they're allowed to pick & choose what they're going to do.

Liz, I think you did ask me this before, but I wasn't able to find a supplier locally. I need to call Medicare and see if they can give me a mail order supplier besides CCS as I don't like them. My current pharmacy does pick and choose - they will only fill a prescription for 30 days even though Medicare and my secondary insurance says I can have 90 days. Very inconvenient.